This study tries to understand the complex phenomena related to the governance of immunization services in Kerala, India where, after basic immunization reached high coverage in the late 1990s, started to decline in some of the regions. The study applied system thinking lens and used a qualitative case study approach to explore the underlying phenomena governing vaccination coverage in two districts in Kerala, one with high and one with low coverage. The study identified four phenomena that influenced change in vaccination coverage.

Background

Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. The conventional approaches often fail to take this complexity into account and expect that technically sound programs ensure successes when necessary management processes are in place. In India, the Universal Immunization Program (UIP), introduced in 1985, targets around 27 million infants and 30 million pregnant women every year and is one of the largest in the world. In one of the high performing Indian states, Kerala, after basic immunization had reached high coverage in the late 1990s, it started to decline in some of the regions.

Objectives

We applied a systems thinking lens to understand the contexts, processes and complex phenomena which led to changes in vaccination coverage over the past three decades in Kerala and the reasons underlying these changes. The analysis expands our understanding of the governance of immunization programs operating in a complex system and thus, enables an understanding of, not only for Kerala but also for the other contexts, where public health programs are showing similar complex behavior.

Methodology

We used a qualitative case study approach to explore the underlying phenomena governing vaccination coverage in two districts in Kerala, one with high and one with low immunization coverage. Data collection included in-depth interviews with private and public providers; beneficiaries and other stakeholders, as well as focus group discussions with mothers of under-five children and observations of vaccination-related activities. Content analysis for the qualitative data aimed to identify and describe the complex, adaptive phenomena resulting from immunization programs in our study area. Causal loop diagrams were developed to depict the phenomena, key actors, and their interactions.

Results

We identified several complex phenomena that influenced change in vaccination coverage levels in the two districts. For example, we identify a phase transition from acceptability to resistance of receiving vaccination services due to the involvement of new actors. The causal loop diagram illustrated several balancing and reinforcing feedback loops that resulted from actions of actors attempting to regain vaccine acceptability and others who counteracted these actions. For instance, mothers who played a major role in decision making during the acceptance phase were replaced by the male members of the household during the resistance phase. The male members were influenced mainly through media which used a negative incident related to child vaccination to create a polemic that influenced their behavior and stance with respect to child vaccination all together. The conventional public health approach that is designed to target mothers through health information and female community health workers did not manage to counteract the influence of media since they are not designed to directly target the male members of the household.Path dependence is another phenomenon where new events influenced the way the decision to vaccinate by households was shaped in two different regions and the speed by which this happened. For instance, the special vaccination campaigns where the entire state machinery mobilized its resources to increase smooth operations were seen as a soft target by groups among naturopathy and homeopathy systems that traditionally opposed vaccination and propagated their misgivings against immunization programs. Finally, the emergence of social networks and their power to influence the change in either direction was detected. Health Worker’s status as a local woman known to the other members of the community gives her special advantage in influencing community perceptions on immunization issues

Conclusion

This study offered a rich understanding of the interactions between multiple actors and contexts and the various phenomena that resulted from these interactions, influencing households' decision to vaccinate their children. Understanding these interactions, including the power exercised by each actor at different points in time, the factors determining the exchange of information, and the norms guiding the institutional mechanisms for immunization functions, clarified how the societal actions changed from acceptance to resistance to vaccinate. Understanding vaccination coverage using a systems thinking lens offered a robust framework to explore the underlying complex mechanisms and contexts that influence policies. The framework also emphasized the importance of considering all the actors beyond health systems. It can be applied in other public health contexts to define problems and guide the analysis.